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Cultural setting and sex and gender of the patient are important factors affecting the occurrence, severity, clinical course and prognosis of pain and pain-related diseases. Intercultural differences in the perception and verbal expression of symptoms and emotional function are fundamental and it is important to realize these differences in order to understand patients with a migration background. A trusting doctor-patient relationship is generally very sensitive and it is even more difficult to establish when differences in the cultural background impair mutual understanding. Regarding sex and gender there is evidence that females are more susceptible to developing chronic pain conditions, experience more severe pain and respond differently to pain therapy; however, results of recent studies indicate that females are not that different to males when comparing several modalities of experimental pain (although some differences exist). Similarly, sex and gender differences in postoperative pain seem to exist but the differences are relatively small when pain scores are compared. Other aspects, such as the response to analgesics and role of psychosocial factors should be addressed when sex and gender aspects are studied. Similarly, sex and gender differences in the prevalence of chronic pain exist but the results of some studies, e.g. those controlling for confounders, are not very clear. Research is needed to delineate the role of specific aspects affecting sex and gender differences and the underlying mechanisms (e.g. reduced inhibitory control, hormones, psychological aspects and social factors). Altogether, we need to open our minds to some intercultural and sex and gender aspects in the clinical setting. For sex and gender differences we may need a more biopsychosocial approach to understand the underlying differences and differentiate between sex and gender and sex and gender-associated aspects for acute and chronic pain.

Background: Primarily used for treating malignant pain, opioids are recently applied for chronic non-tumor pain. For the lack of evidence based strategies from long-term studies, opioids are discussed controversially, esp. considering cost-benefit. Objectives: The purpose of this study is to evaluate characteristics in prescribing opioids for tumor and non-tumor pain conditions. Study design: Cost effectiveness study/observational study Setting/Methods: Health insurance data of a German statutory health insurance company (N = 6.800.000, data acquisition from 2006 to 2010) was evaluated by assigning opioid prescriptions to certain pain related diagnoses using CART (Classification And Regression Tree) segmentation analysis. Age- and gender-specific characteristics of prescriptions were calculated. Results: The number of prescriptions of opioid prescriptions increased linearly. Prescriptions of mild opioids were decreasing for non-tumor pain, but increasing for tumor pain, while the number of prescriptions of strong opioids was increasing both for tumor and nontumor pain. Differences occurred in terms of duration and kind of the preferred substances, including the considerations of common contraindications (e.g. somatoform disorders). The majority of strong opioids being prescribed for non-tumor pain were fentanyl pain patches for 40 to 45 year old males with average annual costs of 1833 Euros per patient. Out of 21000 patients with somatoform pain disorder, 44.4% were treated with opioids (20.7% with mild, 23.7% with strong opioids). Limitations: The results did not consider if the opioid medication was actually taken by the patients. Another difference in terms of representativeness might occur since the gender distribution varies between the official statistical data and data collected by the health insurance company. Because of the acquisition of the data, no conclusions about possible correlation of pain syndromes and educational and social classes are possible. Tumor patients who received an opioid prescription for non-tumor pain could not be excluded. Conclusions: While the overall expenditure of the health insurance companies increased, it remains unknown which patient is receiving a particular opioid medication. Prescribing behavior was often not consistent with common indications and contraindications. Key words: Opioid therapy, chronic pain conditions

Zielstellung und Hypothese: Anliegen dieses systematischen Review mit anschliesender Metaanalyse war es, den Einfluss des aktiven Fusballsports auf das Kniearthroserisiko (Relevanz als Berufserkrankung) zu untersuchen. Als Hypothese wurde formuliert: Fusballer leiden auch dann unter einem erhohten Risiko fur eine Gonarthrose, wenn sie keine dokumentierten Makroverletzungen des Kniegelenks erlitten haben. Methode: Fur das systematische Literaturreview und die anschliesende Metaanalyse wurden die PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Checklisten eingehalten. Zum Stichtag 1.2.2014 wurde eine systematische Recherche in den Datenbanken PubMed, Medline, Cochrane, EMBASE und Web-of-Science durchgefuhrt. Insgesamt 4649 Publikationen einem „Title-Abstract-Review“ unterworfen und schlieslich 6 Publikationen in die Metaanalyse eingeschlossen. Ergebnisse: Eine Langsschnittuntersuchung an einer Gesamtbevolkerung, die den Einfluss des Fusballsports auf das Gonarthroserisiko untersuchte, wurde nicht gefunden. Ein systematisches Cochrane-Review existierte ebenso nicht. In den Studien, in denen nur diejenigen Falle berucksichtigt wurden, bei denen keine Makroverletzung stattgefunden hatte, bestand im Vergleich zu den jeweiligen Kontrollgruppen ein signifikant erhohtes Risiko, eine Gonarthrose zu erleiden: 1,3 (95 % CI 1,0 – 1,7); I2 = 37,4 %; p = 0,002. Ohne Adjustierung auf dokumentierte Makroverletzungen oder einen Meniskusschaden haben Fusballer ein signifikant erhohtes Gonarthroserisiko: (Relatives Risiko = 2,9 [95 % CI 2,0 – 4,1]; I2 = 56,3 %; p Schlussfolgerungen: Im Hinblick auf die grose Heterogenitat der Belastung des Fusballerknies, aufgrund des Fehlens der Kenntnis uber ein belastungskonformes Schadensbild und im Hinblick auf das Fehlen einer „Verdopplung des relativen Risiko in der exponierten Gruppe“ wird derzeit keine „BK-Reife“ und auch kein Tatbestand „wie-BK“ bezuglich der Gonarthrose beim Profifusballer gesehen.

Experts in criminal, civil and, increasingly, in social court cases have to present their expert opinions in court. This should be regarded not only as a burden, even if this may at times appear superfluous to the expert, perhaps because the discussion is mere repetition of the opinion he has already written, or because the questions appear to be biased against the expert. Nonetheless, the expert is always advised to appear calm and objective during the interrogation by judges and parties or participants and their legal representatives, and should not allow himself or herself to be provoked by questioning. Furthermore, it may be necessary to correct the written expert statement in the course of the interrogation, but this can be a sign of a truly competent medical expert. The expert consulted can be held liable for adverse health effects resulting from the interrogation and investigation, as well as for deliberate or grossly faulty reports.Ein Sachverständiger muss in Straf-, Zivil- und zunehmend auch in Sozialgerichtsprozessen damit rechnen, dass er sein Gutachten vor Gericht mündlich erläutern muss. Dies sollte nicht nur als lästige Pflicht empfunden werden, selbst wenn sein Auftreten ihm zuweilen als überflüssig erscheinen mag, weil sich die Erörterung in der bloßen Wiederholung des bereits schriftlich Niedergelegten erschöpft oder die Befragung vermeintlich oder tatsächlich zu unsachlichen Angriffen gegen seine Person instrumentalisiert wird. Gleichwohl ist ihm bei der Befragung durch Richter und Parteien bzw. Beteiligte und ihren Rechtsvertretern stets ein ruhiges und sachorientiertes Auftreten zu empfehlen, insbesondere sollte er sich nicht provozieren lassen. Andererseits spricht es nicht etwa gegen, sondern für die Kompetenz eines medizinischen Sachverständigen, auch zur Korrektur seiner schriftlichen Aussagen bereit zu sein, wenn und soweit dies im Laufe seiner Vernehmung erforderlich sein sollte. Der Gutachter kann haftungsrechtlich für Gesundheitsschäden durch die Befragung und Untersuchung wie auch für vorsätzlich oder grob fahrlässig fehlerhaft erstellte Gutachten belangt werden.

In numerous legal areas, expert assessments are needed to clarify the causality of herniated discs: Was the damage caused by an accident? The literature mentions specific requirements regarding the trauma mechanism as well as temporal criteria, which prescribe the causality test. These are essentially high-energy traumas with immediate functional impairments. Accident-related MRI examinations are of paramount importance in the expert assessment process to confirm the primary body harm. In examining the causality constituting liability, competitive causes must be assessed. Since the legal requirements of the causality test differ in civil and social law, legal norms need to be taken into account. We present a test scheme that supports the assessment process through entry, implementation and decision-making levels.In einer Vielzahl von Rechtsgebieten soll der Sachverständige die Kausalität von Bandscheibenschäden klären: Ist der Schaden Folge eines Unfalls? Die Literatur nennt spezifische Anforderungen an den Traumamechanismus sowie zeitliche Kriterien, welche die Kausalitätsprüfung vorgeben. Es handelt sich im Wesentlichen um hochenergetische Traumen mit unmittelbar einsetzenden Funktionsstörungen. Unfallnahe MRT-Untersuchungen haben im gutachterlichen Beurteilungsprozess überragende Bedeutung zur Sicherung des Körpererstschadens. Bei der Prüfung des haftungsbegründenden Zusammenhangs müssen konkurrierende Ursachen gewürdigt werden. Da sich die juristischen Anforderungen der Kausalitätsprüfung in Zivil- und Sozialrecht unterscheiden, bedarf es der Kenntnis der Rechtsnormen. Ein Prüfschema wird vorgestellt, das den Begutachtungsprozess über Einstiegs-, Realisierungs- und Entscheidungsebene unterstützt.

Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence-based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation. Refereed/Peer-reviewed

The assessment of cervical spine injuries is not a problem - provided full evidence of primary physical damage can be ensured. MRI examinations of the cervical spine carried out soon after the accident provide the best evidence. The assessment is more difficult if only clinical abnormalities are documented by the doctors after the accident in the diagnosis of cervical spine distortion, as functional results of this type are not specific and are also common in the general population. The legal rules of evidence must be taken into account in the summary assessment of the consequences of cervical spine injuries. Testing schemes are available which allow structured assessment of cervical spine injuries and help to avoid incorrect assessments.

Der Zusammenhang von Bindungsverhalten und Schmerzerleben wird kontrovers diskutiert, der Einfluss von Bindungsstilen auf Zytokinspiegel bei chronischen Schmerzen ist wenig erforscht. Diese prospektive Longitudinalstudie untersucht daher den Bindungsstil, die Zytokinspiegel und die subjektive Schmerzbeeintrachtigung bei Patienten mit Fibromyalgiesyndrom (FMS) unter 4-wochiger multimodaler Schmerztherapie. Der Bindungsstil von 43 FMS-Patienten wurde mit dem Relationship Questionnaire (RQ-2), die Schmerzbeeintrachtigung mit der deutschen Version der West Haven-Yale Multidimensional Pain Inventory bestimmt. Die Serumspiegel der proinflammatorischen Zytokine Tumor-Nekrose-Faktor(TNF)-α und Interleukin(IL)-8 sowie der antiinflammatorischen Zytokine IL-4 und IL-10 wurden jeweils zu Therapiebeginn und -ende bestimmt, bei 18 gesunden Kontrollen dagegen nur einmalig (Bio-Plex-System). FMS-Patienten sind signifikant haufiger unsicher gebunden als gesunde Kontrollen (p = 0,001). Die Serumspiegel von TNF-α (p = 0,001) und IL-10 (p = 0,039) der FMS-Patienten sind signifikant hoher als in der Kontrollgruppe. Unsicher gebundene Patienten weisen einen signifikant hoheren Serumspiegel von TNF-α auf als sicher gebundene Patienten (p = 0,002). Die IL-4-, IL-8-, und IL-10-Spiegel ebenso wie die subjektive Schmerzstarke, Gesamtaktivitat und subjektive Beeintrachtigung unterscheiden sich hingegen nicht zwischen sicher und unsicher gebundenen Patienten. Die Zytokinspiegel korrelieren nicht mit Schmerzstarke und Beeintrachtigung. Eine multimodale Schmerztherapie wirkt sich unabhangig vom Bindungsstil positiv auf Schmerzstarke, Angst und Depression sowie Zytokinspiegel aus.

Ruckenschmerzen sind einer der haufigsten Grunde fur eine Konsultation in der Arztpraxis. Leider ist das diagnostische und therapeutische Vorgehen oft nicht evidenzbasiert. Die haufig durchgefuhrte Bilddiagnostik bietet bei den meisten Patienten keine zusatzliche Information. Monomodale Therapiestrategien sind in aller Regel wirkungslos, da sie die multifaktorielle Genese der Beschwerden nicht berucksichtigen. Die Nationale VersorgungsLeitlinie Kreuzschmerz empfiehlt bei akuten Ruckenschmerzen, den meist gutartigen Spontanverlauf abzuwarten. „Red flags“ helfen dabei, keine spezifische Ursache zu ubersehen. „Yellow flags“ mussen beachtet werden, um eine Chronifizierung der Beschwerden zu verhindern. Die prognostisch wichtigen psychosozialen Kofaktoren werden nach wie vor haufig ubersehen. Empfohlen wird, eine interdisziplinare Diagnostik durchzufuhren. Die Therapie sollte multimodal erfolgen. Fur die Versorgung von Patienten mit akuten und chronischen Ruckenschmerzen bietet die VersorgungsLeitlinie praxistaugliche und evidenzbasierte Algorithmen.

The aim of this study was to identify inflammatory mediators of potential clinical relevance in synovial fluid (SF) samples of patients with knee osteoarthritis (OA). Therefore, radiographic OA severity, knee pain and function of 34 OA patients undergoing unicompartmental (UC) and bicompartmental (BC) knee arthroplasty were assessed prior to surgery and SF samples were analyzed for a broad variety of inflammatory mediators, including interleukins (ILs), interferons (IFNs), C-X-C motif ligand chemokines (CXCLs), and growth factors (nerve growth factor, NGF, vascular endothelial growth factor, VEGF, and stem cell growth factor &beta, SCGF-&beta, ) using multiplex assay. Significant differences were observed between the SF levels of different inflammatory markers. When compared to UC OA, significantly higher concentrations of IL-7, IL-8, IL-10, IL-12, IL-13, IFN-&gamma, VEGF and CXCL1 were detected in BC OA. Correlation analyses revealed significant associations between OA severity and IL-6, IL-8, IFN-&gamma, VEGF, CXCL1. Interestingly, increases in both anti- (IL-10, IL-13) and pro-inflammatory (IL-7, IL-12, IFN-&gamma, ) cytokines, as well as growth factors (SCGF-&beta, VEGF), correlated significantly with the level of knee pain. Poorer knee function was associated with higher IL-6, IL-10, IL-12, IL-13, IL-18, &beta, NGF, SCGF-&beta, VEGF and CXCL9 levels. In conclusion, this study provides an extensive profile of synovial inflammatory mediators in knee OA and identifies cytokines of potential clinical relevance. In fact, five of the mediators examined (IL-10, IL-12, IL-13, SCGF-&beta, VEGF) significantly correlate with both knee pain and function.

Nach den Empfehlungen der Nationalen VersorgungsLeitlinie »Kreuzschmerz« sollte bei 6-wochiger Schmerzdauer trotz leitliniengerechter Therapie bei positivem Nachweis von Risikofaktoren zur Chronifizierung ein umfassendes interdisziplinares Assessment stattfinden, um die Indikation zu einem multimodalen Therapieprogramm zu prufen. In diesem Beitrag werden die notwendigen Themenbereiche, die Inhalte und die beteiligten Disziplinen sowie der Umfang eines interdisziplinaren schmerztherapeutischen Assessments beschrieben, die von der Ad-hoc-Kommission »Multimodale interdisziplinare Schmerztherapie« der Deutschen Schmerzgesellschaft e. V. erarbeitet wurden.

A 64-year-old man with chronic low back pain had been treated with tramadol, meloxicam and metamizole for several years. Due to additional neuropathic pain in the lower extremities, the medication was complemented with carbamazepine. After 5 weeks of treatment, the patient developed maculopapulose exanthema and fever, followed by hepatitis, leukocytosis and eosinophilia. The patient was diagnosed with so-called DRESS (drug rash with eosinophilia and systemic symptoms) syndrome, a severe anaphylactic reaction to carbamazepine treatment. Immunosuppressive therapy was complicated by an additional septic reaction. After recovery, the patient was referred to our clinic for a multimodal pain therapy. Fear, depressive episodes and fear-avoidance behavior were additional social factors responsible for the chronic pain syndrome of the patient. The previously diagnosed neuropathic pain syndrome cannot be verified. After appropriate modification of therapy, the patient's pain perception was significantly reduced, allowing for complete withdrawal of pain-relieving medication. This case report illustrates that merely pharmacological treatment of chronic pain syndromes bears only little prospect of success but increased risk of side effects.

This case report presents the medical history of a patient suffering from chronic knee pain with specific heat phobia who had a long history of sick certificates. Using multimodal pain therapy and biofeedback therapy the acquired anxiety disorder could be solved. Long-term working ability could be achieved.

Background: The concept of attachment is relevant for the onset and development of chronic pain. Insecure attachment styles negatively affect therapeutic outcome. Insecurely attached patients seem to be less able to sustain positive effects of a multimodal treatment program. However, it has never been tested before if an attachment-oriented approach can improve treatment results of insecurely attached patients in a multimodal outpatient setting. To test this assumption, we compare the short- and long-term outcomes for pain patients who will receive multidisciplinary, attachment-oriented treatment with the outcomes for patients in a control group, who will receive the multidisciplinary state-of-the-art treatment. Methods: Two patient groups (baseline, attachment intervention) are assessed before treatment, after treatment, and at a 6 month follow-up. The study is conducted in a block design: After data collection of the first block (controls) and before as well as during data collection for the second block (treatment group), the health care personnel of the outpatient pain clinic receives training on attachment theory and its use in the therapeutic context. Pain intensity as measured with visual analogue scales and physical functioning will serve as the primary outcome measures. Discussion: The design of our study allows for a continuous exchange of experienced team members, which may help bring about concrete attachment related guidelines for the enhancement of therapeutic outcome. This would be the first attempt at an attachment-oriented improvement of multimodal pain programs. Conclusion: An attachment-based approach may be a promising way to enhance long-term treatment outcomes for insecurely attached pain patients. Trial registration: DRKS00008715 (registered on the 3rd of June 2015).

Background: Arising from the relevance of sensorimotor training in the therapy of nonspecific low back pain patients and from the value of individualized therapy, the present trial aims to test the feasibility and efficacy of individualized sensorimotor training interventions in patients suffering from nonspecific low back pain. Methods and study design: A multicentre, single-blind two-armed randomized controlled trial to evaluate the effects of a 12-week (3 weeks supervised centre-based and 9 weeks home-based) individualized sensorimotor exercise program is performed. The control group stays inactive during this period. Outcomes are pain, and pain-associated function as well as motor function in adults with nonspecific low back pain. Each participant is scheduled to five measurement dates: baseline (M1), following centre-based training (M2), following home-based training (M3) and at two follow-up time points 6 months (M4) and 12 months (M5) after M1. All investigations and the assessment of the primary and secondary outcomes are performed in a standardized order: questionnaires – clinical examination – biomechanics (motor function). Subsequent statistical procedures are executed after the examination of underlying assumptions for parametric or rather non-parametric testing. Discussion: The results and practical relevance of the study will be of clinical and practical relevance not only for researchers and policy makers but also for the general population suffering from nonspecific low back pain. Trial registration: Identification number DRKS00010129. German Clinical Trial registered on 3 March 2016.

Multimodal therapy has demonstrated good clinical effectiveness in the treatment of chronic pain syndromes. However, within the German health system a comprehensive and nationwide access to multimodal therapy is not available and further improvement is therefore necessary. In order to analyze the current status of multimodal therapy and specifically its structural and procedural requirements and qualities, a survey was carried out in 37 pain clinics with established multimodal treatment programs. An anonymous questionnaire was used for data collection. Results demonstrated that a substantial accordance was found between all pain clinics concerning requirements for space, facilities and staff. Structured multidisciplinary assessments were carried out by all pain clinics even though the amount of time allocated for this varied widely. The main focus of multimodal therapy in all facilities was based on a common philosophy with a cognitive-behavioral approach to reduce patient helplessness and avoidance behavior and to increase physical and psychosocial activities as well as to strengthen self-efficacy. Some differences in the ways and means to achieve these goals could be demonstrated in the various programs.

Zytokine sind Koordinatoren der Immunhomoostase. Belege fur die Beteiligung von Zytokinen an der neurogenen Entzundung, peripheren und zentralen Sensibilisierung sowie Hyperalgesie als auch fur das Auslosen einer proinflammatorischen Immunantwort durch Katastrophisieren als schmerzbezogene Malkognition liegen vor. Ein Missverhaltnis proinflammatorischer und antiinflammatorischer Zytokine als Mitverursacher von Schmerzen und Schmerzverhalten ist anerkannt. Eingebettet in psychoneuroendokrin-immunologische Regelkreise konnten Zytokine einen Circulus vitiosus zwischen lokaler Inflammation und systemischem Schmerzverhalten („pain/sickness behavior“) aufrechterhalten und damit zur Chronifizierung unspezifischer muskuloskeletaler Schmerzen beitragen. In unserem Modell sorgen Vermeidung und schmerzbezogene Malkognition als zentrale Bestandteile des systemischen Schmerzverhaltens fur die Aufrechterhaltung des Circulus vitiosus durch Generierung einer lokalen Inflammation mit lokalen und systemischen Folgen. Dieses Modell kann die Erfolge etablierter Therapiekonzepte fur „fear avoidance“, die im Rahmen der multimodalen Schmerztherapie effektiv genutzt werden, psychoneuroimmunologisch erklaren.

In order to maintain treatment gains achieved during multidisciplinary treatments for chronic back pain, patients are challenged to implement the behavioral changes they learned during treatment into their daily life. Offering support during the critical time after treatment conclusion helps patients deal with relapses, provides them with practical advice and social support, and helps to master this transfer. As in-person offerings are not always feasible, innovative concepts are needed to enable hospitals to provide aftercare to their patients.An Internet-based aftercare intervention following multidisciplinary therapy for back pain was constructed, implemented, and evaluated. The aftercare program comprised two modules: (1) an individualized self-monitoring module and (2) a weekly, 90-min chat session moderated by a therapist whom participants already knew from treatment. A randomized controlled trial (n=75) was conducted that compared the post-treatment symptom developments of program participants with symptom developments of controls (treatment as usual [TAU]).The program was proven to be feasible and well accepted by participants; on average, 68.2% of the participants rated the previous chat session as helpful. Intention-to-treat analyses demonstrated significant effects on post-treatment courses of disability. The largest effects were found for pain-related disability: for TAU participants, disability increased an average of 1.25 scale points (Roland-Morris Questionnaire) per 100 days; for program participants, disability decreased an average of 0.39 scale points (p0.01).The aftercare intervention was shown to be feasible and well accepted. Its efficacy should be tested with a larger-scale randomized controlled trial.

BACKGROUND The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinaren Vereinigung fur Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION The clinical diagnosis of FMS can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with tender point examination), by the modified preliminary diagnostic ACR 2010 criteria or by the diagnostic criteria of the German interdisciplinary guideline (AWMF) on FMS. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Hintergrund Die planmasige Aktualisierung der S3-Leitlinie zum Fibromyalgiesyndrom (FMS; AWMF-Registernummer 041/004) wurde ab Marz 2011 vorgenommen.

Background The effectiveness of multidisciplinary treatment programs varies throughout the literature, and it remains controversial how therapy outcome is affected by patients' individual parameters and which treatment settings work best. Objectives We set out to examine the impact of patient variables on the effectiveness of a 3-week multidisciplinary treatment program in patients with chronic low back pain. By presenting effect sizes, we aimed to enable the comparison of our findings with other studies across disciplines. Methods Data on 395 patients were prospectively collected at study entry, at the end of the program (T1) and after 6 months' follow-up (T2). Relevant therapy outcomes were analyzed by presenting effect sizes with Cohen's d. Group comparisons were performed for sociodemographic and clinical features to determine the impact on therapy outcome. Results Medium effect sizes (d = -0.6 to -0.7) were shown for visual analog scale (VAS) after treatment and at T2, indicating clinically relevant pain relief. Significant changes in pain-related disability were observed immediately at T1 with a strong treatment effect (d = 0.8). Functional capacity was improved with low to medium effect sizes (0.4-0.5). Quality-of-life subscales (36-item Short Form Health Survey) improved significantly at T1 for physical function, vitality, and mental health (d = 0.5-0.8). Center for Epidemiological Studies - Depression Scale scores improved significantly with strong effect sizes of d = 0.7. Sociodemographic parameters displayed a significant impact on effect sizes for visual analog scale at T2, with females (d = -0.9), age group 30 to 39 years (d = -1), and patients with low physical job exposure (d = -0.9) benefiting most. An increase in number of pain locations (-0.7) and severity of accompanying pain (-0.7) in other body areas significantly impaired therapy outcome and effect sizes of VAS. Conclusions Thus, multidisciplinary treatment ameliorates pain, functional restoration, and quality of life with medium to high effect sizes even for patients with a long history of chronic back pain. Effect sizes are higher than for monodisciplinary treatments and treatment effects remained stable at 6-month follow-up in a longitudinal uncontrolled study design. Thus, we believe that multidisciplinary treatment is vital for the treatment of patients with chronic low back pain. The impact of sociodemographic and pain-related parameters needs to be taken into account when including patients in an appropriate treatment program. We emphasize the presentation of effect sizes as a vital treatment evaluation to enable cross-sectional comparison of therapy outcomes.

AIM This metaanalysis was performed to evaluate the prevalence of the radiological assessed knee osteoarthritis in the whole community. MATERIALS AND METHODS Medical databases (Medline, EMBASE, Cochrane) were searched for the strategy: ["Osteoarthritis" and "Knee" and "Prevalence"]. The deadline for the search was 31.12.2009. Two investigators (first and senior author) independently made the selection from 17 studies (from a total of 1428) according to the inclusion criteria: a cross-sectional study of the whole community, radiological investigation and definition of knee ROA by an established radiological score. Only studies in English or German language were evaluated. Effect sizes (event rate, odds ratio [OR] and confidence interval [CI]) were calculated by the software "Comprehensive Metaanalysis V2". Study heterogeneity (I2) was determined accordingly to Higgins. RESULTS The kappa index for interobserver validity was k = 0.948. All studies judged the grade of osteoarthritis according to the Kellgren-Lawrence (KL) score. For calculation of knee ROA KL grades 2+ were estimated only. The total prevalence of knee ROA was 24.3 % (CI 23.4-25.2 %). The whole prevalence in male patients was 24.3 % (CI 23.4-25.2 %); I2 = 59.4 (p = 0.002) and in female patients 32.6 % (CI 31.8-33.4 %); I2 = 49,1 (p < 0.001). Younger male patients (age 50-) had a prevalence of 5.6 (CI 4.5-6.8). In older patients (80+) the male prevalence was 44.5 % (CI 39.6-49.5 %). In this age group female patients had a prevalence of 71.6 % (CI 67.6-75.3 %). The higher prevalence of knee ROA in female patients was significant (OR = 1.8 [1.7-1.9]; I2 = 46.0 [p < 0.001]). The prevalence of knee ROA was higher in male Asians compared with male Caucasians (OR = 1.1, CI 0.9-1.2; p = 0.080) in tendency. This difference was significant in female patients (OR = 2.2; CI 2.0-2.4; p < 0.001). Furthermore another trend was evaluated. Female patients (70-79 years) from the birth-year cohort 1920- had a prevalence of 37.8 % (CI 35.9-39.7)%. In contrast female patients from the birth-year cohort 1920 had a prevalence of 62.8 % (CI 60.8-64.8 %) at 70-79 years. This difference was significant (OR = 2.8; CI 2.5-3.1; p < 0.001). CONCLUSIONS This investigation confirms the high prevalence of knee ROA. The evaluated data may serve as a reference for medical or scientific investigations in the future.

Background Musculoskeletal pain represents a continuous process ranging from single-site to multiple-site pain, with an increase in pain sites accompanied by an increasing risk of chronification and the development of further comorbidities. Within this context, the impact of pain spread on therapy outcome is still unknown. Aims This prospective clinical study aimed to evaluate whether and to what extent patients with pain at multiple sites would also benefit from multidisciplinary therapy or whether therapy success is limited by pain spread. Methods Patients’ characteristics were assessed, including socio-demographic variables, occupational and workplace characteristics, pain intensity and dimensions of pain, psychological aspects and functional back capacity, as well as the generic health status. Data were prospectively collected at day 1 (baseline) and at 6-month follow-up from a sample of 389 patients undergoing multidisciplinary treatment. Patients were distributed into three groups based on the number of pain sites (single-site, dual-site and multiple-site) and the outcome parameters were compared. Results All three groups improved significantly from baseline to the 6-month follow-up. Compared to patients with multiple-site pain, patients with single-site and dual-site pain displayed significantly better outcome on almost all measures. Only the subcategory mental health of the SF-36 did not show any statistically significant differences among the three groups. Conclusions Our results display that patients with two or more pain sites also improve significantly in the outcome measures. Therefore, treatment should be offered independent of the extent of pain spread. However, therapy is significantly less successful in patients with pain at multiple sites.

Opioide als starkste Schmerzmittel nach WHO wurden zunehmend fur chronische muskulosklettale Nichttumorschmerzen eingesetzt. Ziel dieser longitudinalen Studie war es, die Schmerzsensitivitat von Patienten mit chronischen Ruckenschmerzen (CR) unter Opioidtherapie (OT) im Vergleich zu multimodaler Schmerztherapie (MMST) zu untersuchen, um herauszufinden, welche Therapieoption den Patienten bezuglich Schmerzlinderung besser hilft. Es wurden 34 opioidpositive (OP) und 33 opioidfreie (OF) Patienten mit CR einer 3-wochigen MMST unterzogen. Als Kontrolle dienten 28 gesunde Probanden (GP). Vor Therapie und 3 Wochen sowie 6 Monate spater wurden Temperaturwahrnehmungen und Schmerzschwellen durch quantitative sensorische Testung (QST) untersucht. Patienten unter OT zeigten signifikant langsamere Reaktionen fur Warme und niedrigere Kalte- und Hitzeschmerzschwellen als GP, wahrend OF-Patienten nur fur Hitzeschmerz empfindlicher waren. Nach 3 Wochen MMST normalisierten OP-Patienten ihre Temperaturempfindung, aber nicht die Schmerzschwellen, wahrend OF-Patienten keine Unterschiede mehr zu GP aufwiesen. Bezuglich Schmerzlinderung ist MMST einer Daueranwendung von Opioid uberlegen.

Multimodal pain therapy describes an integrated multidisciplinary treatment in small groups with a closely coordinated therapeutical approach. Somatic and psychotherapeutic procedures cooperate with physical and psychological training programs. For chronic pain syndromes with complex somatic, psychological and social consequences, a therapeutic intensity of at least 100 hours is recommended. Under these conditions multimodal pain therapy has proven to be more effective than other kinds of treatment. If monodisciplinary and/or outpatient therapies fail, health insurance holders have a legitimate claim to this form of therapy.Medical indications are given for patients with chronic pain syndromes, but also if there is an elevated risk of chronic pain in the early stadium of the disease and aiming at delaying the process of chronification. Relative contraindications are a lack of motivation for behavioural change, severe mental disorders or psychopathologies and addiction problems. The availability of multimodal pain treatment centers in Germany is currently insufficient.

In this prospective longitudinal clinical study, we evaluated the role of proinflammatory cytokine IL-8 and its clinical relevance in patients with fibromyalgia (FM) who fulfilled clearly defined inclusion and exclusion criteria and underwent a 3-week inpatients multidisciplinary pain therapy.IL-8 in sera was measured in 20 patients with FM and 80 healthy participants at 4 fixed time points: at the beginning of the study, at 10 days, 21 days, and 6 months, respectively. Pain intensity, back function, depression, nicotine/alcohol consumption, and medication were assessed in the patient group and correlated with IL-8 levels.Before and during the inpatient therapy, the serum level of IL-8 was significantly higher in patients with FM compared with controls (P0.001), but did not correlated with pain intensity and medication. Already at T1 there was a significant reduction of IL-8 serum level (P=0.023) in patient group. Six months after multidisciplinary pain therapy, IL-8 serum level in FM patients was still significantly higher than controls (P=0.044) but reduced approximately to normal range and correlated significantly negatively with pain intensity (r=-0.782, P=0.001). Patients with FM had significantly less pain (P0.001) and better back function (P0.001) at day 2 than at day 0. In addition, in patients with FM, IL-8 serum level correlated with nicotine consumption (r=0.471, P=0.042).Our results suggest that IL-8 level contributes in patients with FM whose pain intensity and back function can be improved under influence of multidisciplinary pain therapy without need of an anti-IL-8 therapy.

Eine interdisziplinare Leitlinie zur Therapie des Fibromyalgiesyndroms (FMS) wurde in Kooperation von 10 medizinischen bzw. psychologischen Fachgesellschaften und 2 Patientenselbsthilfeorganisationen erstellt. Eine Literatursuche uber alle kontrollierten Studien zur Patientenschulung des FMS wurde unter Benutzung der Cochrane Collaboration Reviews (1993–12/2006), Medline (1980–12/2006), PsychInfo (1966–12/2006) und Scopus (1980–12/2006) durchgefuhrt. Fur die Vergabe von Evidenzklassen wurde das System des Oxford Centre for Evidence-Based Medicine verwendet. Fur die Vergabe von Empfehlungsgraden wurde die Empfehlungsgraduierung der nationalen Versorgungsleitlinien verwendet. Die Erstellung der Empfehlungen erfolgte in einem mehrstufigen nominalen Gruppenprozess. Den Empfehlungsgrad A erhielten die Patienteninformation bei Erstdiagnose und Empfehlungsgrad B die arztliche patientenzentrierte Kommunikation. Ein abgestuftes Behandlungskonzept in Abhangigkeit vom Ausmas der Adaptation an Beeintrachtigungen von Alltagsfunktionen sowie Ansprechen auf Therapiemasnahmen erhielt den Empfehlungsgrad C. Die Langzeitbetreuung von FMS-Patienten sollte Grundsatze der psychosomatischen Grundversorgung und der gemeinsamen Entscheidungsfindung bzgl. der Therapieoptionen beinhalten.

Hintergrund Eine interdisziplinare Leitlinie auf S3-Niveau zur Diagnostik und Therapie des Fibromyalgiesyndroms (FMS) wurde in Kooperation von 10 medizinischen bzw. psychologischen Fachgesellschaften und 2 Patientenselbsthilfeorganisationen erstellt.

A follow up of 57 wrists with resection of caput ulnae shows different value to different groups of patients. The painful arthrosis of distal radioulnar joint gives indication in posttraumatic cases. Release of pain and improvement of range of motion will be achieved; loss of strength is the most impairing problem for younger patients. 13 patients out of 21 with posttraumatic deformities were satisfied with the post-operative outcome; 13 patients showed significant loss of strength, too. In case of rheumatoid arthritis with caput-ulnae-syndrome the resection is without alternative, needs to be combined with the arthrodesis of radiolunar-joint, if necessary. 20 of 34 rheumatics were satisfied with the outcome after resection of caput ulnae; in 6 cases an ulnar drift was evident, which implied simultaneous or later partial arthrodesis of the wrist. For all patients release of pain decided on their satisfaction with surgery.

The value of sonography for diagnosis of injuries of the acromioclavicular joint was examined in a prospective investigation. In 22 successive patients sonography was used in two defined positions, the results were compared with standard X-rays under weight loading. Only in 9 cases the findings could be controlled during operative exploration. In 16 cases, sonographic and radiologic findings were corresponding, in 6 cases both methods lead to different results. In all corresponding cases sonography was able to demonstrate direct or indirect signs of the damage of acromioclavicular and coracoclavicular ligaments. In the operatively controlled group in all cases the sonographic diagnosis was confirmed.

Insgesamt 6 Beitrage des Sommerworkshops „Schmerz und Bewusstsein“ der Deutschen Interdisziplinaren Vereinigung fur Schmerztherapie e.V. (DIVS) am 27./28. Mai 2005 in Marienfeld werden exemplarisch vorgestellt. Ein Beitrag uber die Schmerzdarstellung im Gehirn legt die Vorteile funktioneller Bildgebungsmethoden dar: Diese erlauben die Charakterisierung von Teilaspekten der zerebralen Schmerzverarbeitung und Mechanismen der Chronifizierung bei Schmerzsyndromen. Ein weiterer Uberblick erlautert den Einfluss unterschiedlicher Analgetika, Sedativa und Anasthetika auf die unterschiedlichen Bewusstseinszustande. Das Krankheitserleben von Ruckenschmerzenpatienten wird in einer Studie mit Hilfe des Erklarungsmodell-Interviews untersucht: Somatische Aspekte dominieren dabei; fur 3/4 der Patienten spielen aber auch psychische Ursachenvorstellungen eine Rolle. Wie Schmerz in verschiedenen Religionsgemeinschaften interpretiert und akzeptiert wird, zeigt eine religionsgeschichtlich-theologische Ubersicht. Ein weiterer Beitrag stellt die Wirksamkeit der Hypnose als erganzende Masnahme anasthesiologischer Verfahren in der operativen Medizin, bei chronischen Schmerzen und bei experimentellem Akutschmerz dar. Mit dem Schmerzerleben in verschiedenen Kulturen beschaftigt sich der letzte Beitrag: Eine einseitige ethnozentristische Sicht kann demnach zu Verstandigungsschwierigkeit und Fehlurteilen bei der Behandlung auslandischer Patienten fuhren. Der Workshop beleuchtete insgesamt in konzentriertem Rahmen wichtige Gestaltungsfaktoren der Schmerzverarbeitung und gab stimulierende Ausblicke auf diesen Teil der Schmerzforschung und kunftige Therapiemoglichkeiten.